Hemodynamic transition driven by stent porosity in sidewall aneurysms
Introduction
Flow diverter stents (FDSs) are endovascular treatments (Byrne et al., 2010, Pereira et al., 2014b) of sidewall intracranial aneurysms (IAs) (Brisman et al., 2006). These expandable tubular devices made of dense mesh of filaments (Fig. 2) are implanted in the parent artery to cover the IA neck, hence reducing the intra-aneurysmal flow known to promote IA thrombogenesis (Zanaty et al., 2014b, Pereira et al., 2014a). Despite the high success rate of FDS treatments, some complications partly related to hemodynamics issues, e.g. subacute aneurysm rupture, parent artery occlusion or flow persistency, have been reported (Brinjikji et al., 2013, Zanaty et al., 2014a). Recently, hemodynamic indicators measured per-operatively with digital subtracted angiography (DSA) (Pereira et al., 2013a, Chien and Vinuela, 2013) or assessed numerically with computational fluid dynamics (CFD) (Pereira et al., 2014c, Mut et al., 2015, Kulcsar et al., 2012, Zhang et al., 2013) were correlated with successful treatment outcomes. These results highlighted the importance of IA flow modifications in the healing process.
During the last decade, the effect of stent implantation in idealized sidewall IA models with straight parent artery was broadly investigated experimentally (Augsburger et al., 2009, Liou and Li, 2008, Liou et al., 2008, Lieber et al., 2002, Yu and Zhao, 1999, Yu et al., 2012, Bouillot et al., 2014a, Bouillot et al., 2015) and numerically (Hirabayashi et al., 2006, Hirabayashi et al., 2004, Kim et al., 2010, Appanaboyina et al., 2008, Bouillot et al., 2015). Although these studies considered various stent configurations within IAs with different size and shape, identical hemodynamic features were reported regardless of the inflow conditions.
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For unstented and high porosity stented IA, an inflow jet at the distal part of the IA neck driving a large vortex was typically observed in IA.
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When decreasing the stent porosity, the IA flow pattern was strongly altered. In general, a diffuse flow was observed at the IA neck with proximal (distal) inflow (outflow) inverted compared with unstented IA.
Recently, we proposed in Bouillot et al. (2014a) a possible physical mechanism describing this hemodynamic transition. Our hypothesis schematized in Fig. 1 involved both shear stress and pressure differential at the IA neck difficult to access experimentally. In the present study, we aim to show the evidence of this description supported with quantitative arguments and hence highlight the universal character of the transition. For this purpose, our recent particle imaging velocimetry (PIV) investigations (Bouillot et al., 2014a) were complemented with CFD simulations providing the non-measurable shear stress and pressure fields. These quantities were analyzed in both unstented/stented idealized IA with different porosities and correlated with IA flows measured by PIV and predicted by CFD.
Section snippets
Experimental and virtual IA models
Fig. 2 shows the idealized sidewall IA geometry considered in the CFD simulations and for the molding of the silicone phantom used in the PIV measurements. In such a model, the stent is expected to expand regularly minimizing the geometry uncertainties in both PIV measurement and CFD simulations. It is composed of a spherical aneurysm of radius R=5 mm located at distance below a straight cylindrical artery of radius r=2 mm. The inlet/outlet length was set in the silicone
Hemodynamic description: PIV–CFD comparison
An overview of the measured and computed velocities for unstentend/stented IA with (S1–3) is provided in Figs. 3 (systole) and 4 (diastole) showing a comparison of the in-plane flow patterns and velocity magnitude as well as a 3D representation of the computed streamlines along with Q-isosurfaces highlighting the vortical structures. A movie of their time evolution during the full cardiac cycle is also available online. The two distinct regimes described in the introduction were observed:
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In
Hemodynamic transition
We have identified various qualitative and quantitative evidences of the two shear and pressure mechanisms (Fig. 1) driving the two main hemodynamic regimes for unstented/high porosity and low porosity stented IA:
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The flow patterns were in agreement with the expected IA flow in both regimes. In particular the inflow–outflow inversion at the neck with low porosity stent was located at the inversion point of pressure differential through the stent.
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The waveform of SAVs followed the time dependence
Conclusion
By combining experimental and computational methods, we showed qualitative and quantitative evidences of the shear and pressure mechanisms driving the flow in unstented/high porosity and low porosity stented IA, respectively. These results suggest the universal behavior of the hemodynamic transition occurring in sidewall IA while decreasing the stent porosity and hence marks an important milestone in the understanding of IA hemodynamics.
Conflict of interest statement
None declared.
Acknowledgment
This study was supported by Swiss National Science Foundation grant (SNF 32003B_141192).
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